Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer

BMC Cancer, Jul 2016

Background Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients. Methods Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups. Results In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups. Conclusions FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer. Trial registration ChiCTR-TRC-13003562, the date of registration: August 29, 2013.

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Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer

Chen et al. BMC Cancer Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer Lantao Chen 0 1 Lixin Sun 0 3 Yaoguo Lang 1 Jun Wu 1 2 Lei Yao 1 Jinfeng Ning 1 Jinfeng Zhang 1 Shidong Xu 1 0 Equal contributors 1 Department of Thoracic Surgery, Harbin Medical University Cancer Hospital , Harbin, Heilongjiang Province , China 2 Department of Thoracic Surgery, Hainan Cancer Hospital , Haikou, Hainan Province , China 3 Department of Thoracic Surgery, The Fourth Affiliated Hospital of Harbin Medical University , Harbin, Heilongjiang Province , China Background: Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients. Methods: Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups. Results: In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups. Conclusions: FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer. Trial registration: ChiCTR-TRC-13003562, the date of registration: August 29, 2013. Esophageal cancer; Fast-track surgery; Cellular immunity; Humoral immunity Background Since its introduction in the 1990s, the concept of fasttrack surgery (FTS) has gained widespread acceptance and is now considered as a standard of care. FTS also referred to as enhanced recovery after surgery (ERAS) have been implemented in order to enhance recovery, reduce morbidity and mortality rates, and shorten hospital stay after major surgery. The aim of this novel approach to perioperative patient care is to decrease the perioperative stress response to the surgical trauma and thereby leading to a decrease in complication rates in surgery. These promising clinical results lead to the question of whether the concept of FTS also results in better-preserved immune function in the postoperative course. Some researchers believe that FTS also has positive effects on the human immune system, which may result in quicker recovery of postoperative immune function [ 1 ]. Nevertheless, few clinical studies results have reported the impact of FTS on human immunity. Therefore, based on the hypothesis and present evidence of the benefits of FTS, we prospectively studied 276 patients underwent esophagectomy for esophageal cancer who either received FTS pathway or conventional pathway in the perioperative period. In addition to clinical outcome parameters, we analysed the effects of FTS on proinflammatory cytokine IL-6 and CRP levels as well as immunoglobulin and lymphocyte subgroups before surgery and on days 1, 3 and 5 after surgery. Methods Patients and procedures This study was conducted in the Department of Thoracic Surgery at Harbin Medical University Cancer Hospital from October 2013 to December 2014. Inclusion criteria included: age ≥18 and ≤75 years, American Society of Anesthesiologists (ASA) grade I/ II, body mass index (BMI) 18.5–27.5 kg/m2, resectable esophageal cancer (page 36, NCCN Guidelines version 1.2013). However, we found in our previous clinical study involving patients with confounding factors that such factors might have a great impact on the results, such as immunological parameters for both controlled and observational groups. Therefore, some patients needed to be excluded from our study. The exclusion criteria of the study were as follows: patients with known immunological dysfunction (advanced liver disease (decompensated cirrhosis, portal hypertension or hepatocellular carcinoma), HIV infection, hepatitis C virus infection), (...truncated)


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Lantao Chen, Lixin Sun, Yaoguo Lang, Jun Wu, Lei Yao, Jinfeng Ning, Jinfeng Zhang, Shidong Xu. Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer, BMC Cancer, 2016, pp. 449, 16, DOI: 10.1186/s12885-016-2506-8